Instructions
Fill out online, print documents and sign. A complete application consists of:
-
Regence Individual Application Cover Sheet
-
Utah Individual Health Insurance Application
-
Authorization for Use and Disclosure of Protected Health Information
Hints
- Answer all questions so we can process your application without delay. Applications that are incomplete or require additional information may receive a later effective date.
- Sign and date all three forms
- Print two copies of each form and keep a set for your records.
Mail a Set of All Three Forms
Regence BlueCross BlueShield of Utah
2890 E. Cottonwood Parkway
PO Box 30270
Salt Lake City, Utah 84130-0270
The effective date will be the first of the month following receipt of an application, upon approval, unless otherwise indicated.
